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It’s a common practice for doctors to keep a patient in the hospital “under observation” when their condition needs monitoring, but may not require an extended hospital stay to stabilize. Even a patient who stays overnight in the hospital may still technically be considered an outpatient under observation. But what does this mean for your clients?

A few important things to know about the difference between being an outpatient under observation and an admitted inpatient.

Costs for the same services over the same timeframe can vary significantly depending on patient status – Because patients under observation are still considered outpatients, their treatment is covered by Part B. Once admitted as an inpatient, Part A takes over coverage for any required services. Because the deductibles and coinsurance are separate, the cost can vary for clients who have certain Medicare Supplement plans. For example, a client with Plan G would pay nothing for an inpatient stay, since their plan covers both the Part A deductible and Part A coinsurance, but would pay Part B charges out-of-pocket until the Part B deductible is met. While Medicare Advantage plans may not mirror the same inpatient and outpatient deductibles in their coverage, their copays and deductibles likely still differ between inpatient and outpatient services.

Outpatient observation days do not count towards a qualifying hospital stay for skilled nursing facility care – To be eligible to have skilled nursing facility care covered under Original Medicare and a Medicare Supplement plan, a member has to first have a qualifying hospital stay of at least three days. Time spent under observation, even preceding an inpatient stay, does not count towards the required hospital days. However, Medicare Advantage plans will vary and many do not require a previous inpatient stay.

Only a specific doctor’s order can change a patient’s status from outpatient under observation to inpatient – Inpatient status is not a factor of the length of time spent in the hospital. A patient could theoretically go to the ER, spend hours in the ER being evaluated, then be moved to a regular hospital bed for another day or more for observation, and never officially be admitted to the hospital. Only once a doctor determines that a patient requires a full inpatient stay and writes an admitting order is someone considered an inpatient.

Some Medicare Advantage plans will not charge an Emergency Room copay and a hospital copay for the same day – Under some MA plans, the ER copay is waived if you’re admitted to the hospital during the same visit, but this does not apply if you stay in the hospital under observation and are then released.

It’s easy to assume that being in the hospital is enough to qualify as an inpatient, but it’s important to remember that there can be more to it than simply being in a hospital bed.

The first thing many clients ask when presented with a new plan is “can I keep my doctor?” It’s an easy enough question to answer with a quick search in a provider directory or a quick call to member services, but there can be more to it than a simple yes or no.

Here are some things about provider networks your clients need to be aware of before they choose a plan.

Networks can change at any time – Providers can drop their contract with a plan essentially whenever they want. A provider who is in network when the plan year starts or when a client becomes Medicare eligible won’t necessarily still be in network even just months or weeks in the future.

Different plans from the same carrier can have different networks – Some carriers have certain plans with lower costs or more robust benefits than their other plans. In exchange, these plans have smaller networks. It’s not enough to know that a provider works with a certain carrier, you also have to be sure that they’re in network for the specific plan in question.

Every doctor in a practice may not be in network for a certain plan and carrier – In most cases, an entire practice or medical group will be contracted together with a particular carrier. However, there are times when this may not be true, depending on how the business side of the practice is run. It’s a good idea to double check on each provider individually, even if it’s providers who share an office.

They may have a Special Election Period if their doctor leaves the network – If a carrier makes significant changes to their network, CMS may determine that affected members are eligible for a one time SEP to move to a different MAPD. In California, they’re also likely eligible for guaranteed issue into a Medicare Supplement plan in accordance with the Knox-Keene Act, with certain restrictions.

They may have continuity of care allowances – Some carriers will allow a grace period during which they’ll allow their members to see providers who have left the network while they transition to a new provider. This is typically limited to members who are considered in active treatment, and the timeframe can vary.

Making sure clients understand the ins and outs of their plan’s network will help them get the care they need and help you keep a happy client.

Sales events are a great way to generate leads and get clients the information they need, but there are some things to consider to make sure your events are both successful and compliant.

Event Registration

Get your registrations in early. – CMS requires that all events be entered into their system at least seven days in advance. However, many carriers have stricter requirements. Generally you should plan to get the appropriate registration forms to your FMO (or the carrier if you’re contracted direct) at least two weeks in advance. Check with your FMO or broker services for deadlines for specific carriers.

Understand the difference between formal and informal events. – If you’re going to stand up and give a presentation, that’s a formal event. If you’re going to be at a booth or table and take people’s questions as they come by, that’s informal. Having your event registered correctly can potentially save you an allegation or discipline from carriers.

If you need to change or cancel an event, you need to give at least 48 hours notice, barring a natural disaster or similar emergency. – If the event was advertised, you have to either advertise the change or cancellation in the same manner the original event was advertised, or you or someone standing in for you have to be at the original location at the original time for at least fifteen minutes.

Venue Choice

Think about accessibility for clients who use things like walkers or wheelchairs. – Wherever possible find an ADA compliant location. It’s also a good idea to look for someplace that doesn’t require extensive walking from parking to the actual venue.

Figure out a head count. – How many people do you expect to attend? You want to make sure you have enough space for everyone to be comfortable and have adequate seating, but you’ll likely spend more than necessary if you reserve a space much larger than you need.

Remember that choice of location reflects on you and the companies you do business with. – You don’t necessarily need to pick anything upscale, but pick something family friendly and where a wide range of people will feel comfortable.

Make sure your location is easy to find. – Someplace on a small side street or down an alley or in a back corner of a crowded complex can make it hard for clients to find your event. If you’re holding your event in a particular room of a larger building like a hospital or community center, find out if the venue will allow you to put up signs near the main entrances directing people to the correct room. It’s also a good idea to include the room number or room name in any advertisements if possible.

Presentation

Show your personality, but avoid going too far off script. – If attendees have questions, gauge whether the answer is relevant to other people and if not, tell the client that you’ll be happy to discuss it with them in more detail after the meeting. Also, be wary of sensitive topics like politics and religion. While they can sometimes overlap with health care, they can also turn off clients who may have differing opinions. Stick to the facts, at the very least until you’re dealing with someone one-on-one and have a sense of how they’ll react.

Use a presentation from a trusted source. – If you want you use a slide presentation or some other kind of visual aid, check the marketing materials from the carriers you’re presenting. Most carriers have presentations, flip books, posters, or some other visual aid that you can use. CMS also has downloadable presentations on a range of topics available here.

Sales events are a great way to build your business, as long as you plan ahead!

We know that long term care costs are rising and can have a catastrophic affect on the finances of seniors and their families. Having a dollar amount to put on those costs can help you impress upon your clients the importance of long term care planning.

Take a look at the national average annual cost.

Type of Care

Annual Cost

Annual Cost Increase Over Past Five Years

Homemaker Services (help with household chores, etc)

$44,616

2%

Home Health Aide

$45,760

1%

Adult Day Care

$17,904

3%

Assisted Living Facility

$43,200

2%

Nursing Home

$80,300 semi-private room, $91,250 private

4%

Unsurprisingly, the average cost in California is noticeably higher.

Type of Care

Annual Cost

Annual Cost Increase Over Past Five Years

Homemaker Services (help with household chores, etc)

$51,480

2%

Home Health Aide

$52,624

2%

Adult Day Care

$20,000

0%

Assisted Living Facility

$45,000

1%

Nursing Home

$89,396 semi-private room, $104,025 private room

4%

And remember, these are national and state averages. In areas in and around San Francisco, for example, home health services average over $60,000 a year and nursing home care runs well over $100,000 a year even for a shared room, reaching as high as $175,000 for a private room.

It’s also important to note that while single digit percentage increases may not seem like much on the surface, long term care has costs increasing faster than the rate of inflation. These are real, net cost increases, not simply cost of living adjustments.

People typically don’t like feeling like they’re being sold on something, especially when it comes to something as important as their health insurance. If you give your clients the information they need, they can make their health care decisions with confidence and without you ever needing to give them a sales pitch.

Here are some things to remember to make your presentations more educational.

Clients will feel most comfortable if they really understand their plan. – Whatever plan a client chooses, they’ll be happiest if they know what to expect in terms of copays, premiums, deductibles, networks, and added benefits. Disappointment and frustration can set in when a client expects something to cost a certain amount of work a certain way and it doesn’t.

Clients want to feel like you respect their intelligence. – You may be the expert on insurance, but clients want to be spoken to as intelligent adults and not talked down to. Even if they need the absolute basics explained, treat them with respect and give them the information they need in a way they can understand.

Explain what they need to know instead of showing off what you know. – All the interesting, complex things you know don’t matter. What matters is that clients get the information that they need. Resist the urge to use unnecessary jargon and go off on tangets. Explain the terminology they do need to know and don’t waste your client’s time with excessive information.

If you approach client meetings less as elaborate sales presentations and more as conversations with someone you care about, all of this will come naturally, leaving your clients well-informed and confident.

Some doctors are beginning to switch to a concierge practice model, where they offer comprehensive services for a flat annual or monthly fee instead of charging patients for each individual service they receive. Some practices may also provide additional personalized services like a wider range of available appointment times or after-hours phone or email access to doctors.

This practice model can work with Medicare, but there are specific things to be aware of if a client is considering coordinating their Medicare benefits with a concierge practice.

Many concierge practices simply don’t take insurance at all – Many providers are switching to the concierge model to avoid the limitations on reimbursement from Medicare or private insurance and to save them the work of submitting claims. If a client’s existing doctor is considering switching to a concierge model, it’s important for them to find out if the practice will remain willing to work with the Medicare program at all, or will be opting out entirely.

Concierge practices cannot charge access fees or administrative fees without providing additional benefits to members – If a concierge practice that does still accept Medicare assignment charges any kind of administrative or membership fees to Medicare beneficiaries, they must be providing some kind of services to the member beyond what would be covered by Medicare. If not, the fee is considered double billing and is against federal regulations. See page 15 of this document.

If a provider in a concierge practice has opted out of Medicare entirely, the member cannot file claims themselves – Providers who have opted out of Medicare are required to enter into a private agreement with patients, entirely removed from Medicare. This includes members paying out of pocket for services and then filing a claim with Medicare themselves. If a provider has opted out, any services offered are no longer considered Medicare eligible.

We know you all want to steer clear of any compliance issues, so here are a few of the most common mistakes you need to avoid.

Agent Phone Number DisclaimerÂ – Anything other than business cards that includes an agent’s phone number must note that calling that number will connect someone to a licensed agent.

Network Restrictions – When enrolling clients in an HMO, make sure any network limitations or referral requirements are clearly and completely explained. It’s also important to make certain that clients are aware that providers can leave networks if they choose. This is probably the single most common reason for sales allegations.

Font Size – All text on any marketing or plan materials must be at least Times New Roman 12 point (or equivalent). This does not apply to television ads, internal tracking numbers, taglines as part of logos, or announcements placed in the Public Notices section of a newspaper.

Promising Formulary Exceptions – Agents cannot promise that a carrier will grant a formulary exception to cover a member’s prescription drug. You can explain that the client can request an exception, but you must inform them that the decision rests entirely with the plan.

Misrepresenting Plan Availability – If there are plans available to a client that you as an agent do not offer, you still must inform the client that there are other options that they can consider.

Using “Best”, “Highest Ranked”, or Other Superlatives – Any absolute superlatives (best, highest ranked, most popular, etc.) cannot be used unless they are backed up by data that is provided to CMS for review. This *includes* qualified superlatives like “one of the best” or “among the most popular.”

Cross-selling – If you uncover additional client needs that you could help meet with other types of products, you can certainly offer those, but it must be at a separate appointment from Medicare products. What’s on the Scope of Appointment is all that can be discussed that day.

Advertising Sales Events – Sales events cannot be advertised before they are submitted and approved by carriers and CMS. Events must registered as “advertised” if any form of advertisement (including flyers on bulletin boards or similar) is going to be used.

And remember, we’re here to help if you have any questions or concerns about compliance, so don’t be afraid to reach out!

Maintaining the independence to stay in their homes is a high priority to most seniors, and emerging technology may make that easier. Things like home monitoring systems, telehealth programs, and new types of mobility aids can help future generations of seniors avoid lengthy nursing home stays. As a result, this can help them preserve their savings, peace of mind, and independence.

What needs to happen to help keep seniors in their homes?

Seniors need better access to reliable, affordable cell phone and internet service – Things like home monitoring systems require high speed internet service, and telehealth services often make use of video calling features on newer smart phones. Access can be limited in rural areas and the costs can be prohibitive for seniors with limited income.

Providers and members have to think beyond brick and mortar – Some seniors may be reluctant at first to use telehealth services or other technology, and will need support to get accustomed to it. Providers may also shy away, fearing their senior clients won’t use new technology and the effort to implement it will go to waste.

Get Medicare and carriers on board – Seniors will only use most of these new technologies if at least some portion of the cost is covered by Medicare or secondary insurance. Medicare and carrier guidelines need to be updated to handle claims for these new services.

We’ve embraced technology in so many areas of our lives, it’s only a matter of time before we do the same thing when it comes to caring for our seniors.